What is tongue-tie?

Tongue-tie, also known as ankyloglossia, is a variation in the tissue connecting the underside of the tongue to the floor of the mouth.

The frenulum is a normal anatomical structure. Some babies have a frenulum that is more prominent or restrictive, while others have a visible frenulum that does not cause any problems at all.

This is why simply seeing a frenulum does not tell us whether a baby has a clinically significant tongue-tie.

The more important question is:

Is the frenulum actually restricting tongue function, and is that restriction contributing to a problem?

A baby who feeds comfortably, transfers milk effectively and is gaining weight appropriately may not need any treatment simply because a frenulum is visible.

What problems can tongue-tie cause?

When tongue movement is restricted, some babies may have difficulty using their tongue effectively during feeding.

Possible feeding difficulties include:

• difficulty achieving or maintaining a deep latch
• repeatedly losing suction
• clicking or smacking sounds during feeding
• prolonged or frequent feeds
• difficulty transferring milk
• coughing, spluttering or struggling to manage milk flow
• maternal nipple pain or damage during breastfeeding
• difficulty gaining weight.

However, these signs are not specific to tongue-tie.

A baby can have feeding difficulties for many different reasons, including positioning, latch, milk supply, oral-motor coordination, jaw position, muscle tension or other medical or developmental factors.

This is why an assessment of the whole feeding picture is so important.

Is tongue-tie responsible for colic, reflux or unsettled behaviour?

This is an area where parents can easily become confused, particularly when searching online or seeing information on social media.

Hiccups, reflux, colic, crying, unsettled behaviour and sleep difficulties are sometimes attributed to tongue-tie. However, these symptoms can have many different causes and should not automatically be assumed to be caused by a restrictive frenulum.

If your baby has one of these symptoms, it is important to consider the wider clinical picture rather than looking for a single explanation.

A tongue-tie may be relevant to feeding, but it is not a diagnosis that explains every difficulty a baby may experience.

Is it tongue-tie, torticollis or a retracted jaw?

Sometimes a baby's feeding difficulties occur alongside physical asymmetry.

You may notice that your baby:

• prefers looking to one side
• finds it harder to turn their head in one direction
• appears tighter through one side of the neck
• seems uncomfortable in certain positions
• has a jaw that appears set backwards
• has difficulty opening their mouth widely.

This does not automatically mean that your baby has torticollis or that tongue-tie is responsible.

There can be overlap between feeding mechanics, jaw position, neck movement and whole-body tension.

For example, a baby may have genuine muscular restriction following birth. Another baby may have a positional preference without a significant neck restriction. A baby may also have a restrictive frenulum alongside these findings.

This is why we look at the relationship between these different factors, rather than assuming that one finding explains everything.

Can birth affect tongue-tie?

Birth does not cause a true anatomical tongue-tie. The lingual frenulum develops during embryological development.

However, a baby's pregnancy, birth and early feeding experience can be relevant when we assess their overall physical presentation.

Some babies may show asymmetry, altered muscle tone or jaw and neck tension following birth. Instrumental delivery, caesarean birth, positioning and other aspects of the individual birth history may therefore form part of the clinical history.

This does not mean that these factors have caused a tongue-tie.

Instead, they may help us understand the wider physical and feeding picture around the baby.

How is tongue-tie assessed?

A tongue-tie should not be assessed by simply looking underneath the tongue.

A proper assessment considers function as well as appearance, particularly how the tongue is moving and how the baby is feeding.

A trained practitioner may look at things such as:

• tongue lift
• tongue extension
• tongue lateralisation
• the shape and movement of the tongue
• the baby's ability to maintain suction
• sucking patterns
• swallowing and coordination
• the baby's feeding history
• maternal comfort and milk transfer.
• The Hazelbaker assessment tool

One tool used by trained practitioners is the Hazelbaker Assessment Toolfor Lingual Frenulum Function (HATLFF).

The tool considers both the appearance of the frenulum and several aspects of tongue function.

Another assessment tool used in the UK is theBristol Tongue Assessment Tool (BTAT).

These tools can help structure an assessment, but a score should not be viewed in isolation.

There is no single score that tells us automatically whether a baby needs a frenulotomy.

The baby's feeding history, observed feeding, tongue function, weight gain and the impact on both baby and parent all need to be considered.

Who can assess a tongue-tie?

Depending on the situation, several healthcare professionals may be involved in assessing a baby's feeding and tongue function.

These can include:

• lactation consultants and infant-feeding specialists
• midwives
• health visitors
• doctors
• dentists
• speech and language therapists
• specialist tongue-tie practitioners
• appropriately trained healthcare professionals working within their professional scope.

At Osteopathy West London, our role is to assess the whole baby, including physical and feeding-related factors.

If we suspect that restricted tongue movement may be contributing to the presentation, we can recommend that parents seek a specialist tongue-tie or infant-feeding assessment.

We believe this is preferable to telling a parent that their baby definitely has a tongue-tie before appropriate specialist assessment has taken place.

The importance of a feeding assessment

For a breastfeeding baby, a lactation consultant or appropriately trained infant-feeding professional can provide an important part of the assessment.

They may look at:

• positioning
• latch
• milk transfer
• sucking and swallowing
• maternal nipple pain
• feeding duration
• feeding frequency
• baby's weight gain
• whether the baby is maintaining suction.

They can also help parents protect their milk supply if feeding has become difficult.

If a baby is not transferring milk effectively, expressing or pumping may sometimes be recommended alongside breastfeeding while the feeding problem is being assessed.

Supporting the mother's milk supply should not be overlooked while parents are trying to establish what is happening with their baby.

Where does osteopathy fit in?

Osteopathy can be one part of the puzzle.

At Osteopathy West London, our paediatric assessment may consider:

• asymmetry
• head and neck movement
• muscle tone
• jaw position and movement
• facial and oral tension
• suckling and feeding-related function
• whole-body movement
• the baby's birth history.

We are interested in whether there are physical factors that may be contributing to the baby's feeding or positional difficulties.

Treatment is gentle and tailored to the individual baby.

The aim is not to “release” or remove a tongue-tie.

Osteopathy cannot lengthen or divide a restrictive frenulum.

Instead, it may help address associated musculoskeletal restriction, asymmetry or tension that may be present alongside the feeding difficulty.

Can osteopathy replace a frenulotomy?

No.

If a baby has a genuinely restrictive frenulum that is causing significant functional difficulties and, following appropriate assessment, a frenulotomy is considered clinically appropriate, osteopathic treatment cannot physically release that restriction.

However, this does not mean that every tongue-tie needs to be divided.

The decision should be based on function and the individual baby's circumstances, rather than simply the appearance or grade of the frenulum.

This is where multidisciplinary care can be particularly valuable.

A lactation consultant may assess feeding and milk transfer.

A specialist tongue-tie practitioner may assess the frenulum and whether division is appropriate.

An osteopath may assess the baby's physical presentation, including asymmetry, muscle tone, jaw and neck movement and whole-body tension.

These assessments can complement one another.

Does every tongue-tie need surgery?

No.

Some babies have a visible frenulum but feed effectively and do not require treatment.

The presence of a tongue-tie does not automatically mean that a frenulotomy is necessary.

The decision to proceed should take into account whether there is a functional problem that is genuinely related to the restricted tongue movement, and whether conservative feeding support has been appropriately considered.

This is particularly important because a frenulotomy is a procedure. Even though it is generally quick, parents should understand why it is being recommended and what benefit is expected.

What is a frenulotomy?

A frenulotomy is a procedure in which the restrictive lingual frenulum is divided to allow greater movement of the tongue.

In young babies, the procedure may be performed using sterile scissors. Some private practitioners also use laser techniques.

The procedure and aftercare will depend on the practitioner and clinical setting.

Parents should have the opportunity to discuss:

• why the procedure is being recommended
• what functional problem it is intended to address
• what the procedure involves
• pain management
• possible complications
• feeding immediately afterwards
• follow-up and aftercare.

It is also important to understand that releasing the frenulum does not necessarily resolve every feeding difficulty immediately.

If other factors are contributing to feeding problems, these may still need to be addressed.

Snip or laser?

You may come across both terms when researching tongue-tie treatment.

In the UK, frenulotomy in young babies is commonly performed using sterile scissors. Laser is also used by some practitioners, particularly in private settings.

Rather than assuming that one technique is automatically better, parents should ask about the practitioner's training and experience, how the procedure is carried out, pain management, possible complications and the recommended aftercare.

The most important question is not simply “Which equipment do you use?”

It is:

“Is this procedure appropriate for my baby, and why?”

What happens after a frenulotomy?

A frenulotomy changes the physical restriction created by the frenulum, but a baby's existing movement and feeding patterns do not necessarily change instantly.

A baby may have spent weeks developing ways of compensating for restricted tongue movement.

After a frenulotomy, some babies may therefore benefit from being reassessed.

At this stage, we may look again at:

• jaw movement
• neck tension
• head position
• asymmetry
• facial tension
• overall body tension
• feeding-related movement patterns.

Where appropriate, gentle osteopathic treatment may be used to address ongoing areas of restriction or tension.

We describe this as helping the baby explore and integrate changes in movement, rather than claiming that osteopathy is necessary for the frenulotomy to work.

Osteopathic treatment does not replace the aftercare recommended by the practitioner who performed the procedure, and ongoing feeding support may still be important.

Finding the right support

If you are concerned about your baby's feeding, you do not necessarily need to start with the assumption that your baby has a tongue-tie.

Starting with a good feeding and physical assessment can help establish what is actually happening.

Depending on your baby's individual needs, this may involve several professionals working together.

Lactation consultant or infant-feeding specialist

Can help with latch, positioning, milk transfer, sucking, swallowing, maternal comfort and protecting milk supply.

Tongue-tie practitioner

Can carry out a specialist assessment of the frenulum and tongue function and discuss whether frenulotomy may be appropriate.

Osteopath

Can assess the baby's wider physical presentation, including asymmetry, muscle tone, jaw and neck movement, suckling and feeding-related function.

If you are looking for a tongue-tie practitioner in the UK, the Association of Tongue-tie Practitioners (ATP) has a practitioner directory, which you can search here.

Parents should always check the individual practitioner's qualifications, professional registration, experience and the services they provide.

At Osteopathy West London

Our approach is to look beyond the frenulum and understand the individual baby in front of us.

We assess asymmetry, muscle tone, jaw and neck movement, suckling and feeding-related function, as well as the baby's overall movement and birth history.

If we identify physical factors that may be contributing to feeding or positional difficulties, we may provide gentle osteopathic treatment.

If a tongue-tie is suspected, we can recommend that parents seek an appropriate specialist assessment rather than assuming that every feeding problem is caused by a tongue-tie.

Where a baby has already undergone a frenulotomy, we can also reassess them afterwards and consider any ongoing asymmetry, tension or movement patterns that may be affecting how they are using their new range of tongue movement.

We work alongside other professionals where appropriate, including lactation consultants and specialist tongue-tie practitioners.

Tongue-tie can be an important part of the puzzle — but it is not always the whole puzzle.

The aim is to understand what is actually affecting your baby's feeding and movement, avoid unnecessary treatment, and make sure you and your baby have the right support from the right professionals.

Would you like to discuss your baby's symptoms?

If you would like to book an appointment for your baby or child at Osteopathy West London, you can book an appointment here.

If you would like to learn more about our paediatric osteopathy appointments for babies and children, you can read our dedicated paediatric page here.